COMMENTARIES

Editorials represent the opinions of

the authors and not necessarily those
of the American Dental Association.

GUEST EDITORIAL


Providing clarity on
evidence-based
prophylactic guidelines for
prosthetic joint infections

T
he notion of biological plausibility—that is, the likelihood of whether
Daniel M. Meyer, DDS
an outcome could occur as a result of a causal association—is
frequently a premise for clinical research as well as a basis for clinical
decision making. However, what do we as clinicians do when the
scientific evidence indicates that a risk factor for a condition, preventive
regimen, or treatment is not probable or likely, despite being conceivable? Do
we follow precedence, inference, or conflicting professional standards of care,
or do we rely on clinical guidelines supported by relevant, scientific evidence
from systematic reviews in the peer-reviewed literature? Should we as health
care providers discontinue providing conventional care when new scientific
evidence from clinical studies indicates a particular therapy or a traditional
antibiotic regimen is not necessary, especially if the risk of potential harms
outweigh the benefits? Such appears to be the case in regard to the results of
systematic reviews in the scientific literature on the use of prophylactic an-
tibiotics to prevent prosthetic joint infections (PJI).
The concept of providing prophylactic antibiotics to prevent PJI has been
based on a logical premise and biological plausibility. Dental procedures that
involve soft-tissue manipulation or bleeding have the potential to introduce
oral bacteria into the blood stream, leading to bacteremia. It has generally
been accepted that bacteremia resulting from dental invasive procedures
could lead to infection of prosthetic joint implant areas. The common
practice, thus far, has been to have patients premedicate with oral antibiotics
before dental treatment to prevent bacteremia and postsurgical infections of
prosthetic joint implant areas. More recent scientific information published
in the peer-reviewed literature is contributing to a greater understanding of
the risks versus benefits resulting from the widespread use of antibiotics.
Consequently, attitudes regarding the indications and contraindications for
antibiotic usage are changing. The overprescribing and overuse of oral
antibiotics are now considered to be a significant public health threat.
Providers, their patients, and the public need to be aware of widespread
antibiotic resistance, adverse drug reactions such as hypersensitivity
reactions, anaphylaxis, opportunistic infections, and Clostridium difficile
infection.
In 2013, the American Association of Orthopedic Surgeons (AAOS), in
collaboration with the American Dental Association (ADA), published the

JADA 146(1) http://jada.ada.org January 2015 3


results of a comprehensive
evidence-based, systematic review
and clinical practice guideline enti-
tled, “Prevention of Orthopaedic
Implant Infection in Patients
Undergoing Dental Procedures:
Evidence-Based Guideline and Evi-
dence Report.”1-3 After conducting
an extensive review of the pub-
lished scientific literature, a multi-
disciplinary expert panel
concluded, “There is no evidence
to demonstrate a direct link be-
tween dental-procedure-associated
bacteremia and infection of pros-
thetic joints or other orthopaedic
implants,” noting, “There is no
evidence that [dental-related] bac-
teremias are related to prosthetic
joint infections.” The published
clinical evidence suggests that there
is no association between invasive
or noninvasive dental procedures
and postsurgical PJIs. Even though
the routine practice of prescribing
antibiotics may be considered by
some providers to be relatively
safe, current scientific evidence
does not support doing so before
performing dental procedures to
prevent bacteremia and post-
surgical PJIs.
Although the AAOS/ADA sys-
tematic review was conducted
thoroughly and was supported by
robust scientific evidence, the clin-
ical guidance stemming from the
review process resulted in consid-
erable confusion among providers
and their patients. In addition,
the 2013 clinical recommendations
were questioned and criticized
for their apparent ambiguity. In
order to provide more clarity for
clinicians, the ADA Council on
Scientific Affairs (CSA) convened
its own evidence-based expert panel
to reevaluate the systematic review
and reassess the clinical guidelines.
The CSA expert panel reviewed the
literature previously conducted by
AAOS, ADA, and other profes-
sional organizations, as well as
additional scientific evidence not
included in the 2013 review and
publication.
4 JADA 146(1) http://jada.ada.org January 2015
COMMENTARIES
The ADA expert panel identified
3 additional studies and reviewed
and evaluated each for its clinical
relevance.4-6 The 3 studies provided
additional clinical data that were
consistent with the original evidence
identified by AAOS and ADA in the
2013 clinical recommendations. The
additional studies provided further
evidence that invasive dental pro-
cedures are not associated with PJIs.
The evidence also indicated that
prophylactic antibiotics taken
before dental treatment do not help
prevent PJIs.
The ADA expert panel
concluded that the benefits of
providing antibiotic prophylaxis to
prevent PJIs do not outweigh the
potential harm for most patients.
In an attempt to provide more
accurate clinical guidance and
clarity, the expert panel drafted new
clinical recommendations that
include a chair-side guide, which is
published in this issue.7 The chair-
side guide was developed to help
dentists and orthopedic surgeons
communicate with their patients
about the potential risks associated
with the use of prophylactic antibi-
otics to help prevent postorthopedic
surgery PJIs.
The new CSA guideline clearly
states that for most patients, pro-
phylactic antibiotics are not indi-
cated before dental procedures to
prevent PJIs. The new guideline
also takes into consideration that
patients who have previous medi-
cal conditions or complications
associated with their joint replace-
ment surgery may have specific
needs calling for premedication.
In medically compromised patients
who are undergoing dental pro-
cedures that include gingival
manipulation or mucosal inclusion,
prophylactic antibiotics should be
considered only after consultation
with the patient and orthopedic
surgeon. For patients with serious
health conditions, such as immu-
nocompromising diseases, it may
be appropriate for the orthopedic
surgeon to recommend an
antibiotic regimen when medically
indicated, as footnoted in the new
chair-side guide.
Instituting these new evidence-
based changes into clinical practice
likely will lead to professional
challenges across disciplines for
providers and their patients. The
new chair-side guide puts at the
forefront of multidisciplined,
collaborative care the need for
dentists and orthopedic surgeons
to work more closely together to
assess each patient’s medical
history, health status, and oral
conditions. The chair-side guide is
designed to be a useful tool for
dentists, orthopedic surgeons, and
patients to use in the decision-
making process. It is intended to
promote supportable, clinically
relevant care that is consistent with
a systematic assessment of the ben-
efits, risks, needs, and preferences of
each patient.
Successful implementation of
these clinical guidelines empowers
medical and dental providers to
use their clinical judgment along
with the support from the best
available scientific evidence on the
potential risks, benefits, and harms.
The guidelines enable dentists and
orthopedic surgeons to engage in
a shared dialogue and decision-
making process with each patient to
minimize risks while optimizing
health outcomes. It is the process of
jointly making a systematic, clinical
decision, rather than the decision
itself, that lends itself to an appli-
cable use of these evidence-based
guidelines.
It is time to rely on scientifically
sound, interprofessional, and cross-
discipline communications to
support beneficial evidence-based
clinical recommendations. Clinical
guidelines that are based on
clinically relevant systematic
reviews enable medical and dental
professionals to provide safe and
effective care—comprehensive,
multidisciplined care that is based
on clinically relevant scientific
evidence instead of customary,

time-honored principles that are
not backed by current research. n
http://dx.doi.org/10.1016/j.adaj.2014.11.009
Copyright ª 2015 American Dental
Association. All rights reserved.
Dr. Meyer is chief science officer, American
Dental Association, 211 E Chicago Ave, Chicago,
IL 60611, e-mail meyerd@ada.org. Address
correspondence to Dr. Meyer.
Disclosure. Dr. Meyer did not report any
disclosures.
1. American Academy of Orthopaedic Sur-
geons; American Dental Association. Prevention
COMMENTARIES
of Orthopaedic Implant Infection in Patients
Undergoing Dental Procedures: Evidence-Based
Guideline and Evidence Report. Rosemont, IL:
American Academy of Orthopaedic Surgeons;
American Dental Association; 2012:325.
2. Rethman MP, Watters W, Abt E, et al. The
American Academy of Orthopaedic Surgeons
and the American Dental Association clinical
practice guideline on the prevention of ortho-
paedic implant infection in patients undergoing
dental procedures. J Bone Joint Surg Am. 2013;
95(8):745-747.
3. Watters W, Rethman MP, Hanson NB,
et al. Prevention of orthopaedic implant
infection in patients undergoing dental
procedures. J Am Acad Orthop Surg. 2013;21(3):
180-189.
4. Jacobson JJ, Millard HD, Plezia R,
Blankenship JR. Dental treatment and late
JADA 146(1) http://jada.ada.org
prosthetic joint infections. Oral Surg Oral Med
Oral Pathol. 1986;61(4):413-417.
5. Skaar DD, O’Connor H, Hodges JS,
Michalowicz BS. Dental procedures and subse-
quent prosthetic joint infections: findings from
the Medicare Current Beneficiary Survey. JADA.
2011;142(12):1343-1351.
6. Swan J, Dowsey M, Babazadeh S,
Mandaleson A, Choong PF. Significance of
sentinel infective events in haematogenous
prosthetic knee infections. ANZ J Surg. 2011;
81(1-2):40-55.
7. Sollecito TP, Abt E, Lockhart PB, et al.
The use of prophylactic antibiotics prior to
dental procedures in patients with prosthetic
joints: evidence-based clinical practice guideline
for dental practitioners—a report of the
American Dental Association Council
on Scientific Affairs. JADA. 2015;146(1):11-16.
January 2015 5